Progress Notes: Template, Formats and 3 Worked Examples

The ScribeMD Team · November 09, 2026

It's 5:40 p.m. Your last patient left twenty minutes ago and you still have eleven follow-up visits to document. Most of them went the way you expected: a blood pressure recheck, a knee that's a little better, a client whose sleep has improved. Each one still needs a progress note that shows what changed, what you did about it and what happens next.

Progress notes are the most common document in most charts, and the easiest to let slide into copy-forward boilerplate. This guide covers what a progress note should contain, the common formats, a fill-in template and three worked progress note examples from different settings.

All patients in the examples are invented. They show structure and level of detail, not treatment advice.

What is a progress note?

A progress note documents a patient's status at a follow-up encounter and how it has changed since the last one. An initial evaluation sets the baseline. A progress note assumes that baseline exists and focuses on change: symptoms, function, response to treatment and the plan going forward.

Progress notes serve three readers at once: the next clinician who picks up the chart, the payer who needs to see that the visit was necessary, and you, six weeks from now, trying to remember why you changed the plan.

What every progress note needs

Whatever the format, a solid progress note covers:

Visit details: date, visit type, who was present, and whether it was in person or telehealth.
Interval history: what has changed since the last visit, including symptoms, function and adherence to the plan.
Objective findings: what you observed or measured today (vitals, exam, scores, test results).
Assessment: your clinical read on progress toward the goal. Is the patient better, worse or the same, and why?
Plan: what changes, what stays, what you're watching for and when the patient comes back.
Signature and credentials.

Progress note formats

The content above can be arranged several ways. Pick the one your setting and payers expect, and use it consistently.

SOAP (Subjective, Objective, Assessment, Plan): the default across medicine and allied health. See our SOAP note template for a full breakdown.
DAP (Data, Assessment, Plan): common in counseling and behavioral health. It merges subjective and objective information into one data section. More in our guide to DAP notes.
BIRP (Behavior, Intervention, Response, Plan): used in behavioral health when the payer wants to see the intervention and the client's response to it.
GIRP (Goal, Intervention, Response, Plan): starts from the treatment plan goal, which makes progress toward goals easy to see.
PIE (Problem, Intervention, Evaluation): a problem-oriented format used in some nursing settings.

Progress note template

This SOAP-based template works in most outpatient settings. Copy it into your EHR's free-text field or a note template and delete the lines you don't need.

Date / visit type / modality: ___
Reason for visit: ___
Interval history: changes since last visit ___ | response to treatment ___ | adherence ___ | new concerns ___
Objective: vitals ___ | focused exam or observation ___ | scores or measures ___ | results reviewed ___
Assessment: status of each problem (improving / stable / worsening) and why ___
Plan: changes to treatment ___ | tests or referrals ___ | patient education ___ | follow-up interval ___
Signature, credentials, date: ___

Progress note examples

Example 1: Primary care follow-up (SOAP)

Visit: 4-week follow-up for hypertension, in person.
Subjective: 58-year-old man seen after starting an antihypertensive four weeks ago. Reports taking it daily and missing two doses. Home readings mostly 130s-140s over 80s. No headache, chest pain, dizziness or swelling. Has cut back on takeout meals, as discussed.
Objective: BP 136/84 (repeat 134/82), HR 72. Weight down 3 lb since last visit. Heart regular, no murmur. No ankle edema. Basic metabolic panel from last week reviewed and within normal limits.
Assessment: Hypertension, improving on current medication and dietary changes, not yet at goal.
Plan: Continue current medication. Reviewed home BP technique. Continue reducing sodium and add walking 30 minutes most days. Return in 6 weeks with a home BP log, sooner for readings consistently above the agreed threshold or new symptoms.

Example 2: Outpatient therapy session (DAP)

Visit: Individual psychotherapy, 50 minutes, telehealth. Session 6.
Data: 34-year-old client in treatment for generalized anxiety. Reports falling asleep within about 30 minutes on most nights since using the wind-down routine, compared with over an hour at intake. Still has worry spikes before work meetings. GAD-7 today 11, down from 15 at intake. Affect anxious at start, brighter by the end. Denies thoughts of self-harm.
Assessment: Partial progress toward the sleep goal. Anticipatory worry about work remains the main target. Client is engaged and completing homework.
Plan: Introduced cognitive restructuring for worry about meetings. Homework: thought record before two meetings this week. Continue the sleep routine. Next session in one week. Review treatment plan goals at session 8.

Example 3: Physical therapy daily note (SOAP)

Visit: Outpatient PT, visit 5 of 12, right knee pain after meniscus repair.
Subjective: Pain 3/10 at worst, down from 6/10 at evaluation. Can now climb one flight of stairs step-over-step holding the rail. Doing the home exercise program most days.
Objective: Knee flexion 115 degrees (evaluation: 95). Extension full. Mild swelling at the joint line. Performed quad strengthening, step-ups and balance work. Tolerated without increased pain.
Assessment: Progressing toward the goals of 125 degrees of flexion and pain-free stairs. Quad strength remains the limiting factor.
Plan: Progress step-up height and add closed-chain strengthening. Update home program. Continue twice weekly. Re-measure range of motion at visit 8.

Progress notes vs psychotherapy notes

In behavioral health these two terms mean different things. A progress note is part of the medical record. It covers session dates, modality, symptoms, assessment, the treatment plan and progress. Psychotherapy notes are a therapist's separate process notes about the content of a session. Under HIPAA they're kept apart from the medical record and receive extra protection. Write progress notes on the assumption that the client, other providers and payers may read them.

Common mistakes

Copy-forward notes. Identical text visit after visit doesn't show progress or medical necessity. Carry the template forward and update the findings.
Assessment without reasoning. "Stable" alone says little. "Stable: BP at goal on home readings, no side effects" says why.
Vague plans. "Follow up as needed" leaves the next clinician guessing. Give a timeframe and the reasons to return sooner.
No link to goals. In therapy and rehab, tie each note back to the treatment plan goals it measures progress against.
Charting days later. Details fade quickly. Notes written the same day are more accurate and easier to defend.

Writing progress notes faster

Most of the content in a progress note was already said out loud during the visit: what changed, what you found, what you decided. An AI scribe listens to that conversation and drafts the note in your format, whether SOAP, DAP or BIRP. Your end-of-day work becomes reviewing and editing rather than typing from memory.

A few honest caveats. Patients need to know the visit is being recorded and give consent according to your practice's policy. You review every draft, fix what's wrong and sign it yourself. The AI doesn't finalize anything. Expect more edits in the first weeks while you tune templates to the way you write. ScribeMD is HIPAA and SOC 2 compliant, supports more than 30 languages, integrates with 35+ EHRs and produces a draft note in under 30 seconds.

If you'd like to see how ScribeMD drafts progress notes from a real visit for you to review and sign, book a demo.